Healthcare Provider Details

I. General information

NPI: 1972369619
Provider Name (Legal Business Name): MISSOURI OCCUPATIONAL MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2024
Last Update Date: 02/21/2024
Certification Date: 02/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 W 12TH ST
WASHINGTON MO
63090-4416
US

IV. Provider business mailing address

PO BOX 1275
WASHINGTON MO
63090-8275
US

V. Phone/Fax

Practice location:
  • Phone: 636-239-0735
  • Fax:
Mailing address:
  • Phone: 636-390-9277
  • Fax: 636-239-0907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1800X
TaxonomyCorporate Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BOBBY ENKVETCHAKUL
Title or Position: PHYSICIAN
Credential: MD, MPH
Phone: 636-239-0735